Melanie Callaway
Rio Rancho
Summary
Dynamic Clinical Documentation Specialist with a proven track record at Presbyterian Healthcare, excelling in documentation improvement and compliance. Recognized for exemplary communication and mentoring skills, I enhance team collaboration and drive quality initiatives, contributing to revenue optimization and improved patient care outcomes. Certified CCDS with strong attention to detail and problem-solving abilities.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Presbyterian Healthcare
Albuquerque, NM
12.2019 - Current
- Reviewed clinical documentation for accuracy and compliance with regulatory standards and collaborated with healthcare teams to enhance documentation practices and improve patient care.
- Member of Second Level Review Team since 2021- Reviewing mortality, surgical, low DRG cases for chart and quality optimization
- Onboarded new staff on best practices for clinical documentation and coding procedures.
- Served as a resource for healthcare professionals seeking guidance on various aspects of clinical documentation, fostering effective communication among team members.
- Mentored staff in via help chat and feedback with disease process questions, coding opportunities, query writing, chart optimization
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- Effectively managed multiple priorities while maintaining strict adherence to established deadlines, ensuring the consistent delivery of exceptional clinical documentation services.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Contributed to revenue optimization by identifying opportunities for appropriate clinical documentation improvement.
- Participated in continuous education programs, staying up-to-date on industry trends and best practices in clinical documentation management.
Registered Nurse
Indian Health Service
Chinle, AZ
01.2018 - 12.2019
- ICU RN in critical access hospital
- Delivered patient-centered care, assessing and monitoring health status for diverse populations.
- Collaborated with multidisciplinary teams to create comprehensive treatment plans for patients.
- Educated patients and families on disease management and preventive health practices.
- Administered medications and treatments in accordance with established protocols and regulations.
Clinical Nurse Manager
Baptist Health
Jacksonville, FL
07.2013 - 01.2017
- Managed 20 bed Progressive care unit, 20 bed medical unit, Interim manager cardiac ICU
- Pioneered Progressive CHF unit and organized CHF readmission reduction plan
- Met biweekly with preceptors and new staff
- Educated staff on new policies and new procedures (without having a designated unit educator)
- Co-chair of the policy and procedure committee; member of the Pharmacy committee
- Led RCA's (Root Cause Analysis) with assistance of Risk Manager
- Led nursing teams in delivering high-quality patient care and ensuring adherence to best practices.
- Developed and implemented operational protocols to enhance workflow efficiency and patient satisfaction.
- Coordinated staff training programs, fostering professional development and improving clinical competencies.
- Monitored performance metrics to identify areas for improvement and drive continuous quality enhancement initiatives.
Clinical Nurse Manager
HCA Orange Park Medical Center
Orange Park, FL
06.2008 - 06.2013
- Managed 22 bed Progressive Care Unit; Managed 18 bed Telemetry unit, Managed Central Monitoring department (Monitor Techs), Interim manager 48 bed telemetry unit
- Assisted in development of post cardiac care unit
- Member of the Recruitment and Retention committee, Member of the Pharmacy committee
- Assisted with conducting RCA's
- Conducted regular performance evaluations, providing constructive feedback to promote staff growth and accountability.
Registered Nurse/Charge Nurse
HCA Orange Park Medical Center
Orange Park, FL
06.2003 - 06.2008
- RN/Charge Nurse of Progressive Care Unit
Education
Master of Science - Nursing Leadership And Management
Jacksonville University
Jacksonville, Florida, FL12-2016
Bachelor of Science - Nursing
Jacksonville University
Jacksonville, Florida, FL05-2003
Skills
- Certified CCDS
- Documentation improvement and compliance
- Exemplary communication skills
- Teamwork and collaboration
- Problem-solving abilities
- Multitasking ability
- Reliability, Adaptability and flexibility
- Training and mentoring
- Strong attention to detail
Certification
- Certified Clinical Documentation Improvement Specialist, ACDIS - 8/1/2022 - Current
Timeline
Clinical Documentation Specialist
Presbyterian Healthcare
12.2019 - Current
Registered Nurse
Indian Health Service
01.2018 - 12.2019
Clinical Nurse Manager
Baptist Health
07.2013 - 01.2017
Clinical Nurse Manager
HCA Orange Park Medical Center
06.2008 - 06.2013
Registered Nurse/Charge Nurse
HCA Orange Park Medical Center
06.2003 - 06.2008
Master of Science - Nursing Leadership And Management
Jacksonville University
Bachelor of Science - Nursing
Jacksonville University